WEST COAST INSURANCE SERVICES – U.S. AUTOMOBILE APPLICATION
West Coast Insurance Services - Jason Wagner, Agent
Auto Quote Worksheet
Ph. (818) 788 - 5353 | Fax. (818) 206 - 4218
Date:
Phone:
Email:
How did you hear about Us or Find Us??:
Requested date:

Applicant name:
Garaging Address:
Mailing Address:
Address #2:
City:
State:
Zip Code:
Current Auto Insurance Company:
Residence: Own Rent    Any other vehicles in house hold: Y N
Tow: Y N    Rental Car: Yes No
Umbrella Liability: Y N    $1million: $2million: $5million: $10million: Other:
Current Life Co. Health Ins LTC Eligible for coverage? Y N
Current Homeowners Co. Since X-Date Dwelling Amount$$
  Name Sex S/M/D Date Of Birth Dr License No. State SSN Year Lic. Ticket/Acc.
Driver1
Driver2
Driver3
Driver4
  Year Make Model Odometer VIN No. Annual Miles Date Purch. How is the Auto used(Biz-Pleasure).
Auto1
Auto2
Auto3
Auto4
BODILY INJURY: 15/30000 25/50000 50/100000 100/300000 250/500000 500/500000
PROPERTY DAMAGE: 5,000 10,000 25,000 50,000 100,000 500,000
MEDICAL PAYMENTS: 1,000 2,000 5,000 10,000 25,000
UNINSURED MOTORIST: 15/30000 25/50000 50/100000 100/300000 250/500000 500/500000
COMPREHENSIVE DEDUCTIBLE: 100

500 		VEH#

VEH#		 1 2 3 4 All

1 2 3 4 All 		250

1,000 		VEH#

VEH#		 1 2 3 4 All

1 2 3 4 All 		COLLISION DEDUCTIBLE: 100

500 		VEH#

VEH#		 1 2 3 4 All

1 2 3 4 All 		250

1,000 		VEH#

VEH#		 1 2 3 4 All

1 2 3 4 All
WAIVER OF DEDUCTIBLE/COLLISION:    YES NO
COMBINED SINGLE LIMIT LIABILITY:    300,000  500,000   Others  
COMBINED SINGLE LIMIT UNINSURED MOTORIST    300,000  500,000   Others  
Occupation? (Discounts may Apply)
Application information 
Employer (him)(her)   
Name
Address
Lienholder Info (Note on back)    REQUEST PAYMENT METHOD
Unless otherwise informed, we will assume no tickets or accidents and youthful drivers quality for good student discounts.
Who may we thank for this referral?
Notes:
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